The deaths of 2 men erstwhile a tugboat capsized connected the Clyde adjacent Greenock was caused by a "breakdown" successful information procedures, an mishap study has found.
George Taft, 65, and Ian Catterson, 73, drowned successful February past twelvemonth erstwhile MV Biter capsized portion assisting the Hebridean Princess cruise ship.
The Marine Accident Investigation Branch (MAIB) said that the velocity of the vessel astir surely caused an "essential" information enactment to break.
Fourteen information issues straight contributed to the accident, including determination being "no shared understanding" of a program betwixt the 2 boats.
Andrew Moll, the main inspector of Marine Accidents, said it was a "cruel acquisition of however rapidly things tin spell dreadfully wrong".
He said: "In little than 10 seconds the tug capsized, and 2 experienced seafarers mislaid their lives, due to the fact that of a breakdown of the systems that should person kept them safe."
Clyde Marine Services, the tug’s proprietor has been ordered to reappraisal its information absorption strategy and hazard assessments, and follow a recognised grooming strategy for tug masters.
The MAIB study said MV Biter and different tug had been assisting Hebridean Princess astatine Custom House Quay erstwhile it was asked to run down the ship.
It recovered that erstwhile MV Biter began to manoeuvre down the Hebridean Princess the ship’s velocity exceeded manufacture guidelines.
The load connected the tug's towlines was besides betwixt 2 and 5 times much than larboard proprietor Clydeport's recommended velocity range.
This caused a "significant load" to beryllium transferred which was "almost certainly" a origin successful the capsizing.
The MAIB besides recovered an unfastened hatch "compromised" the tug’s watertight integrity and constricted the crew’s chance of survival.
Mr Moll added: “Small accepted tugs stay an indispensable portion of UK larboard operations.
"However, the vulnerabilities of these vessels indispensable beryllium understood by those that run and power them.
“Harbour authorities, vessel and tug masters, and pilots should collectively ain this risk."
The MAIB said the velocity of Hebridean Princess placed excessive load connected the MV Biter's gob enactment - which secures the towline to forestall capsizing - and caused this to break.
The study besides highlighted that the cruise ship's maestro and tug masters did not person a "shared understanding" of the program of the Clydeport pilot, who was controlling Hebridean Princess astatine the time.
It was unclear whether anyone understood that determination were "extreme risks" associated with MV Biter’s manoeuvre down the cruise ship.
It recovered the aviator had not worked with tugs similar Biter earlier and "did not understand" what the tug would beryllium doing connected the manoeuvre.
Failure to sermon the program meant that no-one challenged his intentions.
The sinking sparked a large hunt cognition for Mr Taft, from Greenock, and Mr Catterson, 73, from Millport, connected 24 February past year.
Their bodies were recovered successful the Clyde a time aft the incident.
Clyde Marine Services said it would instrumentality clip to "review and consider" the MAIB report.
A spokesperson said: "Our thoughts stay with the families affected and Clyde Marine Services volition proceed to cooperate afloat with ongoing authoritative investigations.”
Clydeport has been approached for comment.